A 2018 report by a New York State medical review board charged with reviewing prisoner deaths determined that at least 50 state prisoners had died within the past five years due to insufficient medical care. The board concluded that the deaths could have been prevented with simple medical or mental health treatment; however, the report is not posted online nor is it readily available even to family members of the prisoners who died.

Todd Heatley was one of those prisoners. When his mother, Maureen, visited him at the Wende Correctional Facility in 2014, the 33-year-old was so distraught that he didn’t recognize her. She cut the visit short and asked staff to get him medical help.

“He was totally disoriented,” she stated.

Before she left, Maureen said a correction sergeant promised he would take care of her son, who was serving a 25-year sentence for murder. The guard didn’t keep his promise, though. Instead, he determined Heatley was not experiencing an emergency and could be handled by medical staff within the next two weeks. Three days later, Heatley was found hanging from a bed sheet in his cell.

The medical review board determined that he might still be alive had he received proper mental health treatment. The board’s report said medical staff with the New York State Department of Corrections and Community Supervision (DOCCS) “failed to recognize the symptom of confusion as a sign of mental illness and institute interventions to provide safety to Heatley until he was evaluated by mental health staff.”

Months later, in January 2015, another prisoner was found hanging in his cell at the Great Meadow Correction Facility. Alfredo Lopez, 54, had been thrown in solitary confinement for being unable to provide a urine sample, which DOCCS deemed a failed drug test – even though the samples he had been able to produce all came back clean.

DOCCS maintains a “shy bladder” roster of prisoners who have difficulty urinating, but Lopez was never placed on that list despite his history of diabetes and nerve damage that made it hard for him to provide a urine sample in the time allotted for the test. Then, while in solitary confinement, his pain medication was taken away.

“I can’t take the abuse any more,” Lopez wrote in his suicide note, claiming he hadn’t slept in 18 days and citing “the mental anguish of being locked up for urinalysis, while all along my system has been clean.”

The death cases examined by the board went back as far as 2013, the year William Stewart, 56, died from an asthma attack at the Groveland Correctional Facility. The medical review of his case found DOCCS staff had failed in multiple areas of his treatment, from not recording vital signs to not documenting medication. Stewart, who was serving a four-year term for drug dealing and assault, received medical care that was “grossly substandard,” the review board concluded.

One of the more famous prisoners whose death was reviewed was Julio Gonzalez, who set fire to the Happy Land nightclub in the Bronx in 1990, killing 87 people trapped inside. Gonzalez, 61, died of a heart attack at the Clinton Correctional Facility in September 2016, but the board said his heart disease had been poorly treated for years.

“His last documented physical was in 2010,” the review board noted.

“As these reports illustrate, it is clear people inside are dying due to inadequate medical and mental healthcare,” observed Jack Beck with the Correctional Association of New York, a prisoner advocacy group.

Part of the problem, Beck said, is that medical expenditures are shrinking at DOCCS, which admitted that contract payments to private mental healthcare providers fell 28 percent in the five years from 2013 to 2018. Concurrently, overall medical staffing in DOCCS was down over 17 percent. While that was partly attributed to a nine percent drop in the prison population during the same time period, starting salaries for healthcare jobs in state prisons are often $10,000 or more below private-sector wages, leaving the department understaffed.

DOCCS currently employs around 89 clinical physicians, 18 physician assistants, 849 nurses and 28 nurse practitioners. But in some cases medical staff positions remain vacant for years. At the Elmira Correctional Facility in Chemung County, a clinical physician position went unfilled from August 2012 through October 2016. Beck noted that some prisons have a single doctor responsible for treating 500 prisoners.

DOCCS officials emphasized that the 50 deaths reviewed by the board represented just a fraction of a percent of the state’s 50,000 prisoners. Nevertheless, the board found multiple cases where prison medical staff neglected basic checkups and mental health screenings, and failed to treat more serious medical problems until they had worsened to the point where death was inevitable.

Multiple mentally ill prisoners committed suicide after they were placed in solitary confinement, though DOCCS maintained that it provides mental health screenings for all prisoners in segregation. At least four deaths from asthma-related problems could have been avoided by giving the prisoners inhalers and medications. DOCCS insiders said staff usually think prisoners are lying about the severity of their medical conditions in order to get better housing or drugs. Until they die, that is.

“How many more avoidable deaths will occur before the state addresses these serious and persistent problems?” Beck asked.

Under a recent lawsuit settlement, prison officials are now required to determine which prisoners suffer from serious mental illness and move them to a Residential Mental Health Treatment Unit, where they leave their cells four hours a day for therapy and programming.

In November 2018, state Assemblyman Richard Gottfried promised to introduce a bill giving the state Department of Health (DOH) more oversight of DOCCS medical staff and treatment. Under the proposed law, DOH would be required to study and report annually to the legislature on medical care in state prisons.

“[Prisoners] are in our custody, and we have a constitutional obligation to protect their health, whether they have done wrong or not,” Gottfried stated.